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CERTiRED
SOURCMG W W W.SIi7ROGRAMI.0:2G
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No 2 Fims. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration for Diopnsal Works Tonstrur#ion 1hrmit
Application is hereby made for a Permit to Construct (L< or Repair ( ) an Individual Sewage Disposal
System at:
------_.........................................
--- ••Location-Address •- or Lot No.
cN. sr. � /�---------------• . .............----- ....-..........................................
a Address
.............
...
Installer Address
Type of Building Size Lot.................... .....Sq. feet
U Dwelling—No. of Bedrooms.............3..........._...............Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............................ No. of persons____________________________ Showers — Cafeteria
a' Other fixtures __________________________________
WDesign Flow........... per person er day. Total daily flow--------
WSeptic Tank—Liquid capacity_�P? gallons Length__ _G_ __ Width._4.� ... Diameter________________ Depth__S. /8�.
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area..........._........sq. ft.
Seepage Pit No........./--------- Diameter..____/Z ____ Depth below inlet.....6....____._. Total leaching area....3Vez3.sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1.L___ ____minutes per inch Depth of Test Pit_._e4_0!_...__... Depth to ground water________________________
Test Pit No. 2__L_ .....minutes per inch Depth of Test Pit.....ZS ...... Depth to ground water........................
.K.
R'+ " ----- ..--------------------------------------
-------------------------a ----•-••---------•----....
Description of Soil_________-O �� -------•-r-3 -7 5�?1 - S -
•-
•-•_-----
V ------•-••••---- -----•---------------------------- ---•----•••----•-••--------
----••--------- -------------------------------------------•-------•----------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
`.
------------------------------------------•--------•-•----.-.-•------...----------..__...--•---•----._.._......----------------------------.-..•------------------------------------------...•--------•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIHE 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
..................... ..........................
.. .......................•---•---._......._.._..•--•----•- C. _ 1y
Date
Application Disapproved for the following reasons:.............................................................................................................
......_••------------•... �............•-__••-. •---•-------•••-•--.._..--•----------..........-•--•--..._._...._...._....._..--------------••---------•--•-----•-•--•-----------••-•------•---•--------
Date
PermitNo......................................................... Issued_.......................................................
Date
l_
- �� f- 13
LOCATION SEWAGE PERMIT NO.
VILLAGE -1
+INSTALLER'S NAME i ADDRESS
-,�7 � � u � ►�
`�-8 U I L D E R OR OWNER
DATE PERMIT ISSUED /
DATE. COMPLIANCE ISSUED
va.
�� r
L 0 CATION SEWAGE PERMIT NO.
VILLAGE _
IN-STA LLER'S NAME i ADDRESS
3 vz c 5
a T W I L-L ! Tl i✓ cv`r t�—
B U I L D E R OR OWNER _
DATE PERMIT ISSUED � 7
DATE COMPLIANCE ISSUED /J 3
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THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
/¢1^/�t/... OF......... i37 .,f/; ;Ti�JG...................................
Appliratiun for Disposal Works Tonstrurtiun Orrunit
Application is hereby made for a Permit to Construct (i j or Repair ( ) an Individual Sewage Disposal
System at:
0!-1-?G�o lv T' 1049...: �"`��`7. :.L-D---....--••--•--- Z'T z t�
.......... -_......_.......... .. ...............••--------.....-• ......-•------......_...---_..........
Location-Address or Lot No.
1 ne Address
W "'�F .� �? ...........................
a ... ::
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms.............3 ....................Expansion Attic ( ) Garbage Grinder ( )
'_l Other—Type e of Building No. of persons............................ Showers
a YP g ... P ( ) — Cafeteria ( )
a Other fixtures .......................••--•----..._._.........
W Design Flow...............-53...................gallons per person per day. Total dais flow........;ZnZ _ gall
ons.
WSeptic Tank—Liquid'capacity..Ag0.G llons Length-_-uo.G.�__ Width...'�__.r." Diameter................ Depth.. ...�..`.�
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft.
Seepage Pit No........./:........ Diameter....../.7r_.... Depth below inlet......G. ...... Total leaching area---- 3I::3sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
1-4 Percolation Test Results Performed bY.......................................................................... Date........................................
Test Pit No. 1_.4_. ....minutes per inch Depth of Test Pit....��.f'..__.. Depth to ground water....................:...
Test Pit No. .....minutes per inch Depth of Test Pit...... Depth to ground water........................
..................•-----------•---•....._____................_........•------••-•-•-..........................................................................
0 Descri tion of Soil........... "3� In!opl��r�-� Su3-.5¢� .-..................................................................
-...
_ �7�� ��/ ---- ------- ------------------•
U -.... --
�l ....------•--•-•-----------•-••---•--------•-•.................•----------••---------.._........••---•-•-•-•-•---------------........------------............_.............---•-•-•-•----•-•-•-•__••.
UNature of Repairs or Alterations—Answer when applicable.........................................................:.....................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIS 5 of the State Sanitary Code— The undersigned >urther agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed..................7...... ..._....
u Date
Application Approved By...... '.?.. ...... ....._.._ ... .. aP ....
Date
Application Disapproved for the following reasons___________________________________________________________________________________________________________-_
-•-•-•-•-•...................•---...............----.....--•--.................--•--------------._...........------------------•-•--•---•----•--•----.........--•-------•--------..................__.._
Date
PermitNo..................................................._.... Issued............................................--..........
Date
L
THE COMMONWEALTH OF MASSACHUSETTS
��� BOARD OF HEALTH
..............r4?kV /.......OF............ f}"�� /�/sl -'� .....
Trrtifiratr of Tounpliana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (4,'ror Repaired ( )
by.......... ....,...:" ."'Q `....................................................................................................... ._...._
rr t ..�. Installer
at............. t. ... .. .---------! YY 1�:�.s2: �t f• .
� c .. -_ . ..................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as,described in the
application for Disposal Works Construction Permit No....;.`�- _..�`►� 1".,.�....... dated.......... ........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUN ION SATISFACTORY.
DATE.................--......! � Inspector - �. 1... ........................ ............_....................--
i
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
+c" .,- �. .....OF..........��� �:�.��.....:�-�. .��...................' -,�-
t.
No....`�...___-•-_•- - F>as...: `a`.............
Disposal orks Tunstrwtiun Vlermit
Permission is hereby granted • •!....1�.............. *r ......-•--•- ............... ...................................._..
to Construct (�f'or Repair ( ) an�vi u Sewage D.i�,po System
at No. :�. :L ={- - .. ........... q._<_..- .cn:� -........_ ' ..� G.tl;ltk...........................................
Street
as Permit-shown on the application for Disposal Works Construction N `_:'.. 2Dated........................:. A...........
` � r ...-•-•----------- --.........................
d .........................................—
Boar o f Health
DATE..............
'
FORM 1255 A. M. SULKIN, INC., BOSTON v« '
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SCALE . � . . DATE ocT.2-3��BS
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CERTIFY THAT THE ... ...... . ... . ..
SHOWN ON THIS PLAN IS LOCATED ON THE GROUND
AS SHOWN HEREON AND THAT IT CONFORMS TO THE
SETBACK REQUIREMENTS OF THE TOWN OF
WHEN CONSTRUCTED.
DATE . . . . . . . . . .. .
C�//�A:G�:$ .S>�}y✓LGy— �G-77TJG+�/�'".E'_ REGISTERED LAND SURVEYOR
i
*5•x/E7e 7- z
TOP OF FOUNDATION
e CONCRETE COVER,
T :,'
CONCRETE COVERS
/o.7/ •'� 4"CAST IRON "MAX. -� �
OR SCHEDULE 4t�2 MA 12"MAX.
• hft
P-V.C. PIPE 4°SCHEDULE 40 PV.C.(ONLY)
' PITCH 1/4•'PER. PIPE- MIN. LEACH
PITCH 1/4•PER.FT. PIT PRECAST
o•,
o' NVERT j LEACHING
e EL...9./.30
INVERT IN VE n . � PIT OR
's SEPTIC TANK o Z DIST. 8 o ° w S' EQUIV.
, e INVERT EL..9.. ..7.. BOX EL........ ' : >= 0;
/noDINVERTF !'
qo • .• .... GAL. ,. G �� o:
e; EL.....t4'¢.. EL n,p7 INVERT , �o \; :_i. 3/4"TO1V2'
EL.. LL WASHED
e � °•• W .�'� STONE
DIA
PROR LE OF GRouND WATER TABLE
• SEWAGE DISPOSAL SYSTEM
NO SCALE ,
SOIL LOG WITNESSED BY :
DATE .17 198-45'TIME. !O:3o A!y 1�1!1E5 --o�/lv.v BOARD OF HEALTH
TEST HOLE I TEST HOLE 2 j> ENGINEER
ELEV. . . . . ELEV. .4/.So. . .
7-727,
Wooa[o,q-►7 WooDCo,gy� . .. . ,
3911 sysc.� 3L„ Sve_so„ DESIGN DATA :
C�,BB,00 NUMBER OF BEDROOMS
TOTAL ESTIMATED FLOW . . 33v . GALLONS/DAY
BOTTOM LEACHING AREA , . . . SO.FT. /PIT/B- C.P.P.
SAr/O S�1-,vc
Wi774 W/ SIDE LEACHING AREA . . .??G•. Z. . . SO.FT./ PIT/s7Sca D•
F/NE 3 �i•v�s GARBAGE DISPOSAL .Na/!/Cs.(50% AREA INCREASE).
TOTAL LEACHING AREA . . 3• lc 3. SQ.FT
EZ,77, /s Z" �L,7B,S
PERCOLATION RATE `''�^! '�� SSG MIN/INCH
/c8 o0
Na. .WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE .�.•�-'.-. SQ.FT./,-,,OD.
NUMBER OF LEACHING PITS
APPROVED . .. . . . . . . BOARD OF HEALTH ��°�' QF .S7DNG O.YLG S/DFS
DATE. . . . . . . . . . . . . . . .
AGENT OR INSPECTOR
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ytiEP S P�(B OF
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p rIo. 26100. . . . . . � t
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/DEAL LAND S 1
. . C'v.�9�'7A�ciiD �.9 5-S s�rert�mpt�
PETITIONER .
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